Smoking, humoral immunity, and ulcerative colitis

Since ulcerative colitis predominantly affects non-smokers and ex-smokers we have examined the possibility that smoking modifies the humoral immune response to an antigenic challenge from the gut lumen. Gut lavage was used in healthy subjects and patients with ulcerative colitis, including both smokers and non-smokers. Antibodies in the intestinal fluid to Escherichia coli (five pooled serotypes), Candida albicans, gliadin, ovalbumin, and beta lactoglobulin were measured by ELISA to determine specific antibody concentrations of IgG, IgA, and IgM classes. Total IgG, IgA, and IgM were also measured in intestinal secretions and serum. In addition, circulating antibody concentrations of IgG, IgA, and IgM to three gut commensals - E coli (five pooled serotypes) C albicans, and Poroteus mirabilis were measured. There was a significant reduction in the IgA concentration in intestinal fluid of smokers with ulcerative colitis compared with healthy non-smoking controls. No other significant differences were found between the groups. Overall, these data are not consistent with the idea that smoking suppresses immune responses in the gut and suggest that the effect of smoking in colitis is mediated by another mechanism.

Gut lavage fluid proteins as markers of activity of inflammatory bowel disease

Intestinal secretions may be obtained by gut lavage using a polyethyleneglycol-based electrolyte lavage solution; concentrations of immunoglobulins and other proteins are readily measured in processed gut lavage fluid. As patients with inflammatory bowel disease (IBD) have greatly increased numbers of IgG-producing intestinal immunocytes, we measured gut lavage fluid IgG levels in 44 patients with IBD with various degrees of disease activity to determine whether total IgG in gut lavage fluid reflects disease activity. We also measured levels of albumin in gut lavage fluid, to determine the degree of plasma leakage. Both IgG and albumin levels in the patients with active IBD were significantly higher than those in controls and patients with inactive IBD (all p less than 0.00001). IgG is a more specific index of disease activity than albumin, with no overlap between levels in controls and patients with active IBD. There was a positive correlation (r = 0.68, p less than 0.0001) between IgG and albumin levels, suggesting that gut lavage fluid IgG is mainly plasma-derived.

Animal model of gluten induced enteropathy in mice

The aim of our experiments was to produce a local T cell mediated immune response to gliadin in the mouse small intestine as a possible animal model of gluten sensitive enteropathy, coeliac disease. BALB/c and BDF1 mice were immunised systemically with gliadin in complete Freund's adjuvant. The jejunal mucosa was challenged by feeding a gluten containing diet, and villus and crypt lengths, crypt cell production rate, and intraepithelial lymphocyte counts were determined to assess mucosal cell mediated immunity. In some animals permeability and local immunity were modulated by concurrent intestinal anaphylaxis or a graft versus host reaction. There were no changes in the jejunal mucosa of BALB/c mice fed a gluten containing diet after having been parenterally immunized. When, however, mice were parenterally immunised with gliadin, fed a gluten containing diet, rendered hypersensitive to helminth antigen by infection with the nematode parasite Nippostrongylus brasiliensis, and challenged intravenously to produce intestinal anaphylaxis crypt cell production rate was significantly higher than in ovalbumin immunized controls at 12 days after parasite challenge. Finally, graft versus host reaction was induced in BDF1 mice that had been parenterally immunised with gliadin and were on a gluten containing diet. Two weeks later these mice had significantly longer crypts and a higher crypt cell production rate and intraepithelial lymphocyte count than control, unimmunized mice with graft versus host reaction. We conclude that active immunization with gliadin does not in itself produce intestinal cell mediated immunity to gliadin contained in the diet, or enteropathy. Additional factors, such as those occurring during intestinal anaphylaxis (increase intestinal permeability), or during graft versus host reaction (enhanced antigen presentation), seem to be necessary for the full expression of a jejunal mucosal reaction.

Adolescent smoking

Most smokers start experimenting with cigarettes in early adolescence. This paper describes the factors which influence the development of the smoking habit. Methods of intervention, both in and out of the classroom, are discussed. Recommendations for further legislation and increased taxation on tobacco are supported.

The clinical entity of orofacial Crohn's disease

The clinical features, treatment and outcome of 29 patients with oral Crohn's disease seen over a 6-year period have been reviewed. Findings on clinical examination included labial swelling (19 patients), buccal mucosal cobblestoning (11), linear ulceration (11), lumps (five), and mucosal tags (two). Eleven patients had multiple features. Eight patients developed symptoms within the first decade of life and nine patients had symptoms for more than 4 years before diagnosis; the mean age at diagnosis was 30 (range 6-78) years. Fourteen of these patients (48 per cent) have Crohn's disease elsewhere in the alimentary tract, and in nine patients the oral disease predated the development or detection of Crohn's disease at other sites. Eight patients (25 per cent) have required no specific therapy for their oral disease and 12 have been treated with systemic corticosteroids of whom three are steroid-dependent. No other pharmacological approach to treatment has been successful and elimination diets, tried by five patients, had no effect. Oral Crohn's disease has a characteristic naked-eye appearance, may be the first or only manifestation of Crohn's disease and usually improves with oral corticosteroid treatment.

Small intestinal function and dietary status in dermatitis herpetiformis

Small intestinal morphology and function were assessed in 82 patients with dermatitis herpetiformis, 51 of whom were taking a normal diet and 31 a gluten free diet. Methods used were histopathological evaluation of jejunal mucosal biopsy specimens, quantitation of intraepithelial lymphocytes, cellobiose/mannitol permeability test, tissue disaccharidase values, serum antigliadin antibodies, and formal assessment of dietary gluten content by a dietician. There was no correlation between dietary gluten intake and the degree of enteropathy in the 51 patients taking a normal diet, whereas biopsy specimens were normal in 24 of the 31 patients on a gluten free diet, all previously having been abnormal. Eighteen patients on gluten containing diets had normal jejunal histology and in seven of these all tests of small intestinal morphology and function were entirely normal. Intestinal permeability was abnormal and serum antigliadin antibodies were present in most patients with enteropathy. Studies of acid secretion in seven patients showed that hypochlorhydria or achlorhydria did not lead to abnormal permeability in the absence of enteropathy. This study shows that a combination of objective tests of small intestinal architecture and function will detect abnormalities in most dermatitis herpetiformis patients, including some with histologically normal jejunal biopsy specimens. Nevertheless there is a small group in whom all conventional intestinal investigations are entirely normal.

Population-based study of surgery in juvenile onset Crohn's disease

A geographically based cohort of 68 children with Crohn's disease was derived by sampling from Scottish Hospital In-patient Statistics. Surgical histories were examined and analysed by actuarial methods, and the nature of major operations performed was compared with operations for Crohn's disease in the Lothians' Surgical Audit. Fifty-four of the 68 patients were treated surgically, with a total of 135 operations (71 major, 64 minor). Fifty per cent of the cohort had a major operation within 5 years of onset of symptoms; median time to a second operation was 4 years. The types of major operation performed in juvenile onset patients differed significantly from those recorded in the Lothians' audit, with a high rate of exploratory laparotomy in younger patients (12 cases). With a mean follow-up of 7 years, 12 patients (18 per cent) have a permanent stoma. There were five deaths, three postoperative. This study highlights the frequency of surgical intervention in young people with Crohn's disease.

Population-based study of surgery in juvenile onset ulcerative colitis

A geographically based cohort of 37 children with ulcerative colitis has been derived by sampling from Scottish Hospital In-patient Statistics. Surgical histories were examined and analysed by actuarial methods, and the major operations performed were compared with operations for ulcerative colitis in the Lothians' Surgical Audit. Fourteen of the 37 patients had a total of 26 operations (15 major, 11 minor). Sixteen per cent had major surgery within 5 years of onset of symptoms, and the types of operation were similar to those recorded in Lothians' Surgical Audit. Operation rate was significantly lower than that for a parallel cohort of patients with Crohn's disease. With a mean follow-up of 7.4 years, seven (19 per cent) patients have a permanent stoma and there has been one death.

A study of mid-arm and chest circumferences as predictors of low birthweight

Nine hundred ninety-nine newborns were examined in order to determine the relationship between birthweight and mid-arm and chest circumstances. An early neonatal mortality rate of 51/1000 was recorded, being much higher for preterm (301/1000) than term babies (2.5/1000). Both mid-arm and chest circumference showed highly significant correlations with birthweight (r = 0.872, P less than 0.0001 and r = 0.918, P less than 0.0001, respectively). The correlation between weight and chest circumstances was upheld even for very small babies.

Dissociation between systemic and mucosal humoral immune responses in coeliac disease

We examined humoral immunity in coeliac disease as expressed in serum (systemic immunity), and in saliva, jejunal aspirate, and whole gut lavage fluid (mucosal immunity). The aims were to define features of the secretory immune response (IgA and IgM concentrations and antibody values to gliadin and other food proteins measured by enzyme linked immunosorbent assay (ELISA)) in active disease and remission, and to establish whether secretions obtained by relatively non-invasive techniques (saliva and gut lavage fluid) can be used for indirect measurements of events in the jejunum. Serum, saliva, and jejunal aspirate from 26 adults with untreated coeliac disease, 22 treated patients, and 28 immunologically normal control subjects were studied, together with intestinal secretions obtained by gut lavage from 15 untreated and 19 treated patients with coeliac disease and 25 control subjects. Jejunal aspirate IgA and IgM and gut lavage fluid IgM concentrations were significantly raised in patients with untreated coeliac disease; the lavage fluid IgM concentration remained higher in patients with treated coeliac disease than in controls. Serum and salivary immunoglobulin concentrations were similar in the three groups. Patients with untreated coeliac disease had higher values of antibodies to gliadin compared with treated patients and control subjects in all body fluids tested; these were predominantly of IgA and IgG classes in serum, and of IgA and IgM classes in jejunal aspirate and gut lavage fluid. Values of salivary IgA antibodies to gliadin were significantly higher in untreated coeliacs, though antibody values were generally low, with a large overlap between coeliac disease patients and control subjects. In treated patients, with proved histological recovery on gluten free diet, serum IgA antigliadin antibody values fell to control values, though serum IgG antigliadin antibody values remained moderately raised. In contrast, there was persistence of secretory antigliadin antibodies in treated patients (particularly IgM antibody) in both jejunal aspirate and gut lavage fluid. Antibody responses to betalactoglobulin and ovalbumin were similar to those for gliadin, including persistence of high intestinal antibody values in patients with treated coeliac disease. There was a positive correlation between antibody values in jejunal aspirate and gut lavage fluid, but not between saliva and jejunal aspirate; thus salivary antibodies do not reflect intestinal humoral immunity.

Appraisal of gut lavage in the study of intestinal humoral immunity

Direct investigation of intestinal humoral immunity requires collection of intestinal secretions or mucosal biopsy specimens, or both. A non-invasive technique of gut lavage, with a polyethyleneglycol electrolyte lavage solution as a means of collecting intestinal secretions for immunoglobulin and antibody studies, was evaluated. Fifty patients were studied--25 immunologically normal patients or volunteers, 15 patients with untreated coeliac disease, and 10 patients with active Crohn's disease. Protease inhibitors were added promptly to samples to prevent proteolysis of immunoglobulin content. Treated lavage samples were assayed by enzyme linked immunosorbent assay for immunoglobulin and antibody content. Studies of serial lavage specimens showed that early, faecally contaminated specimens contained negligible quantities of immunoglobulin, but once the specimens became clear a steady state was reached, with little variation in immunoglobulin content between serial specimens and with a uniform dilution (around 20%) of the ingested polyethyleneglycol. Gut lavage fluid IgA was predominantly secretory, comprising 92%, 81.6%, and 76.7% respectively of the total IgA gut lavage fluid content in the control, coeliac, and Crohn's groups. High values of total IgM and IgA and IgM antigliadin antibodies were detected in the coeliac group, and high values of IgG in the Crohn's disease group. This method of gut lavage is not only an effective bowel cleanser, but also a noninvasive means of obtaining intestinal secretions for the study of humoral immunity in gastrointestinal disease.

Minisatellite DNA fingerprints of salmonid fishes

The human minisatellite probes 33.6 and 33.15 cross-hybridized to DNA digests of Atlantic salmon, brown trout and rainbow trout revealing complex multi-banded patterns. These DNA fingerprints (in excess of 40 resolvable fragments in some cases) were highly polymorphic, individual specific and found to be stable, both somatically and in the germline. Pedigree analysis of an Atlantic salmon family confirmed that the minisatellite fragments showed Mendelian inheritance. With only a single occurrence of linkage and allelism being observed it is likely the minisatellite loci are widely distributed throughout the salmonid genome. The potential applications for both multi- and single locus minisatellite probes in salmonid research are discussed.

Similarities in intestinal humoral immunity in dermatitis herpetiformis without enteropathy and in coeliac disease

Intestinal humoral immunity was examined in eight patients with dermatitis herpetiformis and normal jejunal histology (as determined by quantitative morphometry) on a gluten-containing diet. Jejunal aspirate was taken at the time of jejunal biopsy, and levels of total immunoglobulins (IgA, IgM, IgG) and specific antibody to gliadin and two other dietary proteins, betalactoglobulin and ovalbumin, were measured. The pattern of secretory immune responses in the dermatitis herpetiformis patients was similar to that in twenty-six patients with untreated coeliac disease--ie, higher than normal concentrations of IgA, IgM, and IgG and high levels of specific antibodies (IgA and IgM) to the three dietary proteins. Serum levels of IgA antigliadin were similar in the dermatitis herpetiformis and control (twenty-eight patients who underwent jejunal biopsy to exclude coeliac disease) groups, and serum levels of IgG antigliadin were intermediate between those of the control and coeliac disease groups. These findings suggest that investigation of gut humoral immunity may provide a diagnostic index of latent coeliac disease. The definition of coeliac disease as a permanent gluten-sensitive enteropathy may have to be revised if the proposed two-stage model is confirmed.

Clinical features, morbidity and mortality of Scottish children with inflammatory bowel disease

From the Scottish Hospitals in-patients statistics for the years 1968-1983 all children and teenagers (a total of 1257) admitted to a National Health Service hospital with Crohn's disease or ulcerative colitis were identified. Case records of samples of patients with onset of symptoms at or before age 16 years were examined to establish the features, morbidity and mortality of unselected cohorts of young patients with inflammatory bowel disease. Median delay in diagnosis was less than six months. Anatomical distribution for Crohn's disease was similar to that in adults (small bowel 30 per cent; large bowel 28 per cent; small and large bowel 38 per cent) and almost half the patients with ulcerative colitis had extensive colitis. The morbidity was substantial in both. In-patient days for Crohn's disease ranged from seven to 322, median 64 days and for ulcerative colitis one to 275, median 30 days. At diagnosis, 11 of 40 young children with Crohn's disease but none of 14 with ulcerative colitis, were below the third centile for height. Despite treatment with corticosteroids 72 per cent of patients with Crohn's disease and 30 per cent of patients with ulcerative colitis required surgical treatment. Seventeen per cent have a permanent stoma. There were only six deaths, all before 1978.

Mucosal immunodeficiency in smokers, and in patients with epithelial head and neck tumours

Cigarette smoking influences the risk of orogastrointestinal disease in both protective (ulcerative colitis), and inductive (squamous tumours of the head, neck and oesophagus) roles. In order to study the effects of smoking on mucosal immunity, salivary immunoglobulins were measured in pure parotid saliva from groups of healthy non-smokers, smokers, and exsmokers and from patients with epithelial head and neck tumours, both untreated and after radiotherapy. Of the healthy individuals, smokers had significantly lower salivary IgA and higher IgM concentrations than did non-smokers. The effect on IgA was dose related, and reversible after cessation of smoking. Likewise, in patients with head and neck tumours (the majority being smokers), salivary IgA concentration was reduced and IgM increased when compared with non-smoking controls. Results were similar before and after radiotherapy. This study provides evidence of the effects of smoking on mucosal immunity as evaluated by parotid salivary immunoglobulins. Further studies of the influence of smoking on secretory immunity are indicated.

Coeliac disease and collagenous colitis

We describe a case of collagenous colitis in a young man with coeliac disease who had responded clinically and histologically to a gluten-free diet three years previously. The collagenous colitis responded initially to oral corticosteroid therapy and he is now asymptomatic (and with normal rectal mucosa) on oral mesalazine. Collagenous colitis should be considered in the coeliac patient with diarrhoea despite adherence to a gluten-free diet.

The immune system and mucosal transformation--historical perspective

An intimate association between columnar epithelial cells and lymphocytes within the epithelial layer of the gut and other organs has been recognised for more than a century. Various roles have been postulated for intraepithelial lymphocytes (IEL), nutritive as well as immunopathological. Recently, the relevance of activation of mucosal lymphocytes to some of the development changes in the gut at weaning have been hypothesised, and the relevance of the IEL to the induction of specialised epithelium overlying Peyer's patches remains to be established. Interactions between lymphocytes and the structure of the gut mucosa can readily be studied by using defined animal models in which the state of development of the gut, luminal antigens and bulking agents, host factors such as nutritional status can be defined, and against such background various forms of immune-mediated intestinal injury can be created. The earliest work along these lines was purely descriptive, particularly of the weaning changes, and also concerned the lymphocyte mediated gut damage of allograft rejection and later other models of T cell injury. These experiments clearly showed stimulation of crypt mitosis in immune mediated enteropathy, with crypt hyperplasia, which could not be explained by a feedback stimulation from damaged villi or villus enterocytes. Further work is now showing that mediators released by lamina propria activated T cells influence mitotic activity and differentiation of crypt enterocytes, as well as modifying the rate and patterns of expression of brush border enzymes and expression of cell surface class II HLA antigens.(ABSTRACT TRUNCATED AT 250 WORDS)

Inflammatory bowel disease and male infertility: effects of sulfasalazine and 5-aminosalicylic acid on sperm-fertilizing capacity and reactive oxygen species generation

To investigate the mechanism of the antifertility action of sulfasalazine, we prospectively measured sperm density, motility, hamster oocyte penetration capacity, and reactive oxygen species production in six men with inflammatory bowel disease being treated with sulfasalazine and 8 and 16 weeks after changing to 5-aminosalicylic acid (5-ASA). An improvement was observed after changing to 5-ASA in those with poor (n = 3), but not in those with normal (n = 3), sperm function on sulfasalazine. There was no correlation between reactive oxygen species production or acetylator phenotype with egg penetration capacity, sperm motility, or sperm density. We conclude that the mechanism of impairment and recovery of sperm function on and off sulfasalazine treatment is not related to an excess in reactive oxygen species.

Mortality in celiac disease

The mortality experienced by a cohort of 653 patients with celiac disease in Edinburgh and the Lothian region has been analyzed. Mortality overall was 1.9-fold (95% confidence limits, 1.5-2.2) that of the general population (115 deaths observed, 61.8 expected; p less than 0.0001). The increased mortality was greatest within 1 yr of diagnosis of celiac disease and steadily declined over time with the excess mortality being concentrated at ages 45-54 yr in men and 55-64 yr in women. Celiac disease was mentioned on the death certificate in 33 cases but in only 10 was it given as the underlying cause of death. Of 17 deaths from lymphoproliferative diseases (0.55 expected, p less than 0.001), 8 occurred within 2 yr of diagnosis of celiac disease compared with 8 (0.37 expected, p less than 0.001) occurring greater than 5 yr after diagnosis. Esophageal cancer was certified as the cause of four deaths (0.47 expected, p less than 0.01). In men mortality from all other malignant disease was also increased (15 deaths observed; 6.4 expected, p less than 0.01), but most of these deaths occurred within 5 yr of the diagnosis of celiac disease. In contrast, there was no deficit in deaths from ischemic heart disease or stroke and the mortality rate in those diagnosed in childhood as having celiac disease was similar to the general population.